Record of treatment session

RICOJffi Of TREATMiNT SESSION

Patient's Name:-

Datę:-

Patient Subjective Statement:_

Pain Distribution:

Pain Linę: 0-

■10

Pain Quality: Severe _ Buming

Sharp_

Other_

Mild_

Throbbing Duli_

Moderate

Tingling

Stabbing

Pain Freąuency: (circle one)

PI — pain on one day or less per month P2—pain on two or morę days per month P3—pain on one or morę days per week P4—pain is daily but intermittent P5 — continuous pain

Pain Intensity: (circle one)

II — absent or mild

12—morę than mild but tolerable

13 — moderately severe

14— severe

15— intolerable or even suicide producing